• Feature

    Looking at Physical Therapy Holistically

    There's a growing realization that helping patients achieve optimal health requires addressing both the body and the mind. As a practical matter, though, how does that happen? These PTs are showing the way.

    Looking at Physical Therapy Holistically

    Dan Rhon, PT, DSc, says the need to treat the whole patient extends far beyond the patient's health.

    "The Army's surgeon general has determined that this is a matter of national security, because if you look at current trends, by the year 2030 we will not have a fit enough society to serve in our military and all of our community positions such as police officers and fire fighters," Rhon observes. "These jobs all require some sort of physical and health component. From that perspective—and the military's a snapshot of society—it's a big problem," he says. Rhon is a clinical scientist for the Geneva Foundation, which supports innovative medical research and excellence in education in the US Department of Defense (DoD).

    The concept of holistic health care—whether in the military or elsewhere—isn't new. In 2013, Vice Admiral Matthew Nathan, surgeon general of the US Navy, wrote, "the implications [of poor health] on military readiness are profound," but praised a collaborative approach that "allows us to embed within a primary care environment the psychologists, nutritionists, tobacco-cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the ‘mental armor' our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations."1

    Chronic preventable diseases are the biggest cause of death in the United States today, Rhon adds. This, he says, is in part because health providers often aren't trained to focus on prevention and holistic medicine.

    But what does "holistic medicine" really mean? According to the American Holistic Health Association (AHHA),2 it's the art and science of healing that addresses the whole person—body, mind, and spirit. The practice integrates conventional and alternative therapies to prevent and treat disease—and, most important, to promote optimal health.

    Holistic medicine sometimes is referred to as integrative medicine. According to the National Institutes of Health (NIH), "Integrative health care often brings conventional and complementary approaches together in a coordinated way. It emphasizes a holistic, patient-focused approach to health care and wellness…"3

    In response to the Army surgeon general's warning, the DoD in 2015 created a program, "Move to Health," that examines a number of influences on the patient: exercise; surroundings; personal development; food and drink; recharging; family, friends and coworkers; spirit and soul; and power of the mind.4

    This integrative approach reaches well beyond the military. According to the American Hospital Association (AHA), in 2010, 42% of participating hospitals offered 1 or more complementary or alternative therapies.5 That number was up from 37% in 2007 and 26% in 2005. The top outpatient services cited in the 2010 survey were massage therapy, acupuncture, and guided imagery—which Webster's defines as techniques to guide someone to imagine sensations or images to evoke a desired response. The top inpatient services, meanwhile, were pet therapy, massage therapy, and music therapy.

    A more recent study of children's hospitals found that 92.3% of responding institutions offered 1 or more complementary or alternative medicine (CAM) services, with the most frequent being music therapy, pet therapy, guided imagery, massage therapy, and biofeedback.6

    MD Anderson Cancer Center in Houston offers 75 different types of complementary treatments, including art, guided imagery, yoga, nutrition, and journaling.7 Carol Eddy, PT, MPT, is a senior physical therapist (PT) in the Integrative Medical Center there. She says the institution defines integrative medicine as "interventions that are used together with conventional medicine in a deliberate manner that's personalized. It's evidence-based and safe," she adds. "So, integrative oncology is the application of integrative medicine to the care of people affected by cancer."

    Where Does Physical Therapy Fit Into Holistic Medicine—and Vice Versa?

    So, how does the concept of caring for the whole patient translate to the practice of physical therapy?

    "There are many different levels of complexity," Rhon says. "It's not just 1 thing isolated from everything else. As clinicians, we're often afraid to go outside of our lanes. It doesn't mean that I have to be an expert in sleep management. It just means I may need to be able to screen and identify where there's a problem. And then, just like anything else, I need to know what to do so I can refer and get the patient the right resources."

    Eddy works with clinicians who offer acupuncture, oncology massage, lifestyle modification interventions, nutrition, and health psychology. Her role as a PT in the Integrative Medical Center is to teach patients about the importance of exercise, how to do it safely, and how to integrate it into cancer and survivorship care.

    "There's so much that exercise can do for these patients," Eddy says. "It's a vital part of their treatment in general. The reasons that they should be exercising are many, but primarily in the short term we're looking at improving the effectiveness of their treatment and minimizing the negative impact that their treatments can have on their health, well-being, quality of life, and physical functioning."

    Beyond the immediate cancer therapy goals, Eddy wants patients to treat exercise like a medicine—a standard part of their care plan—to reduce the risk of recurrence, decrease the risk of treatment side effects, and protect them from other chronic diseases.

    Lori Quinn, PT, EdD, is an associate professor of movement science and kinesiology at Teacher's College of Columbia University in New York City. She works primarily with patients who have neurodegenerative conditions such as Huntington disease (HD) and Parkinson disease (PD). Like Eddy, 1 of her primary goals is to help patients understand the role that exercise and daily activity play in their treatment.

    Quinn was a lead author of a study, Engage-HD, in which patients with HD were randomly assigned to 1 of 2 groups to receive either social contact interventions or physical activity interventions.8 Researchers sought to determine if using a physical activity coaching intervention in the earliest stages of the disease led to patients exercising more.

    In her research, Quinn found that there was only so much progress her team could make during their appointments.

    "A patient's day-to-day living will have the most influence or impact on disease progression," Quinn says. "Having patients come in twice a week for 2 hours total, even doing the best exercises, if the rest of the time they are sedentary at home, negates a lot of the benefits. So, we wanted to develop a holistic, whole-person approach."

    "It's not about waiting until the end of the therapy to discharge them with a home exercise program," Quinn says, "but about thinking from the very first day that you're with them: ‘What is this person's life like?' And how can we use the 6 to 8 to 10 weeks that we have together to try to implement a holistic self-management approach that will lead them to make some lifestyle changes?" Among her suggestions: "Use even 5 or 10 minutes at the end of every session to say ‘Okay, how are things going at home?' and really think about barriers and facilitators to exercise and physical activity engagement."

    The therapists' coaching interventions focus on 3 core elements.

    • Promoting autonomy: Helping patients develop their own programs that work within their lifestyle, needs, and environment.
    • Promoting competence: Educating patients to ensure they can recognize barriers (including symptoms of the disease) and still know how to exercise and progress through their exercises.
    • Promoting relatedness: Encouraging therapists to interact with empathy and to develop a rapport with the patient. If a patient is unable to perform an exercise, the therapist must be understanding. Quinn supplies therapists with prepared statements to help frame those interactions.

    "It's about engaging with the patient and not being prescriptive," Quinn says. "It's understanding the barriers they face and being facilitators for them individually. This may take into account their disease and its progressive nature, but it also considers the patient's lifestyle, job, and environment. It then uses all of these factors to construct a coaching model to engage the patient in exercise."

    The study found that those in the physical activity intervention group showed improvements in cognitive function, walking endurance, and a function termed "life space"—meaning they were more likely to get out into their community.

    This approach had a big impact on Manuel Patino, who was diagnosed with PD in 2015. As part of Quinn's Preactive PD study, he met with occupational therapist Katrina Long, OT, in person and over the phone for approximately 12 weeks. During that time he began journaling, set goals, and monitored his exercise and sleep with a Fitbit. In their sessions, he and Long talked about nutrition, sleep, common reactions to medications, and his emotional and mental well-being.

    "First of all, I feel a lot better emotionally," Patino says. "What I never realized is that anxiety and depression can make your life terrible if you have PD. It makes all the symptoms worse. So, I was absolutely pleased any time I would meet with Katrina, especially if my wife, Eileen, came along. There was a lot of resonating, talking, and checking. I found that really helpful."

    Eddy receives equally satisfying feedback from her patients, who she says often tell her they are "extremely grateful" to have found her clinic.

    "We're in position to support patients through a difficult process. I'll often be asked, ‘How do you do this work? Isn't that sad? Isn't it depressing? Don't you get scared for these patients?' Yes, I absolutely do," she concedes, "but my not doing this work is not going to stop them from having their cancer and going through that experience. The fact that I can be here in this way to support them through it is extremely rewarding."

    Treating the whole patient isn't rewarding only for the patient. It also can breathe new life into a therapist's outlook.

    Julie Granger, PT, DPT, owns Performance Rehabilitation & Integrative Sports Medicine, a private practice in Atlanta. She works primarily with active and athletic women and girls, treating everything from orthopedic injuries to pelvic health problems. Granger is a board-certified clinical specialist in sports physical therapy, as well as a women's health coach, certified by the Integrative Women's Health Institute.

    "The actual tools I use in my practice are vast," Granger says. "They include everything from Pilates to dry needling, Redcord to pelvic floor therapy, and functional exercise to running analysis. I make recommendations that I believe will help patients. But then the coach in me comes out and asks, ‘Okay. Which ones feel the best to you today?' And I let them choose. As a provider, this ensures that I don't get burnt out by constantly trying to get them to do what I want them to do. The patient is totally in charge. Ultimately, because the patient chooses, it's a much better experience for both of us."

    Rhon says he has had a similar experience. He became a researcher, focusing on holistic treatments, when, after years as a clinician, he became frustrated that more of his patients weren't getting better, particularly those with complex conditions. "Some patients do respond, but for many, it doesn't seem like anything you do is working. That can lead to burnout. You start realizing, ‘We've got to do things better.'"

    Models for Incorporating Holistic Approaches

    There are many ways PTs can incorporate holistic care into their practice. The choice depends on the nature of the practice, its patients and clients, and the PT.

    Under the multidisciplinary team approach at MD Anderson, Eddy says an oncologist initially refers the patient to integrative medicine. The patient then meets with a physician in Eddy's department who reviews the person's needs and interests before making referrals to different providers.

    "Once those providers have met with the patient," Eddy says, "if we discover there's a need for health psychology, let's say, but the patient was not originally referred to health psychology, we can facilitate that referral."

    And Eddy says that because she can request the referral on the patient's behalf, rather than leaving that task to the patient, the appointment happens faster. "We're all looking out for what the patient needs," she says.

    This same integrative medicine model can include physicians, acupuncturists, nutritionists, and others. The model also can work, Eddy adds, in an office outside a medical center.

    Other holistic models include traditional physical therapy clinics in which each provider has an area of non-physical therapy-specific knowledge, or in which at least 1 provider has such knowledge.

    Z Altug, PT, DPT, is owner of Integrative Physical Therapy & Wellness in Redondo Beach, California, and author of the book Integrative Healing.

    During a new patient's evaluation, Altug asks lifestyle-related questions to determine if the person needs help with matters related to sleep, stress, nutrition, and/or exercise.

    "During my treatments, I may include holistic techniques such as myofascial cupping, instrument-assisted soft tissue mobilization using certain gua sha [traditional Chinese medicine] tools such as flat stones—and aromatherapy and essential oils, using a lavender scent for relaxation during soft tissue techniques," he says. "I also may incorporate some basic yoga, tai chi, or qigong exercises as part of the person's clinic and home program. Finally, I may provide patient education regarding proper sleep habits, stress management strategies, and meditation and relaxation strategies."

    Granger offers some coaching as part of her physical therapist interventions, but she also offers women's health coaching as a separate service. In the latter sessions, she treats clients who have chronic and complex illness and pain, hormone imbalances, fertility problems, autoimmune diseases, and cancer.

    Pain is a common problem and, in line with APTA's #ChoosePT campaign, Granger educates patients about safe alternatives to opioids—including physical therapy.

    She adds, "Research shows that women are not often taken as seriously about their pain as are men. So, teaching them to have a voice is important. That's why coaching is helpful. Also important is teaching them that there's a lot they can do outside of pain medication." The opioid crisis particularly affects women's health, Granger notes, "because opioids and other medications can affect hormone levels and therefore reproductive and mental health."

    In the area of pain management and alternatives to opioids, she often refers her patients and helps coordinate the efforts of a team of specialists.

    "[Patient] follow-through is key, because I have established a large collaborative network of people," Granger says. "Part of coaching skills is helping empower patients to follow through. So, there's a lot of support and accountability."

    Granger's practice is cash-based, and she bills separately for physical therapy and coaching sessions. However, she's happy to help people try to find providers who accept insurance if the payment aspect is an obstacle to care.

    How to Get Started

    Many providers may think holistic elements of health care are "outside their ‘lane,'" Rhon says, even though most people would agree that a multidisciplinary approach is good. "They simply may not know how to actually put that into practice."

    Rhon, who teaches a 1- to 2-day course on incorporating holistic therapy into clinical care, cites 3 levels of assistance a PT can provide without requiring additional professional licensing: (1) handouts, educational information, and self-management tools on a specific topic; (2) screening questionnaires to evaluate the extent of the problem; and (3) referrals.

    "Then I can either coordinate with their primary care provider," Rhon says, "or put in the referral and say, ‘Let's get you to the right place where you can get help.'"

    Altug recommends that PTs take continuing education courses and workshops in an area of integrative medicine—such as yoga, Pilates, tai chi, qigong, meditation, aromatherapy, cupping, or gua sha—that interests them.

    Quinn urges PTs to not shy away from talking about other holistic topics—saying that with neurodegenerative diseases in particular, certain exercises may have a "neuroprotective" effect. She notes, as well, that many of the protocols for Engage-HD trials are published and available.

    "When you have someone in for physical therapy," Quinn says, "there's an amazing opportunity to be able to think about their lifestyle and self-management principles from the very first time you meet them."

    Granger suggests that PTs who want to treat patients more holistically consider earning national board certification in health and wellness coaching. "It offers a nice perspective on how you communicate with the patients," she says. "There's a different energy when you realize that you're not the only one who's solely responsible for the patient's outcome. Also, it is within the PT's scope of practice to make very basic nutrition recommendations. There are many courses now taught to PTs."

    The Future of the Whole Person

    "This is the future," Granger says. "Taking an integrative and more holistic approach to the client will create sustainable outcomes. In the past, it's been about the PT doing the work for the patient—which creates a form of dependency. That might be good for business, but it's not so great for long-term outcomes for patients. If we want them to be able and healthy in the long run—especially in a health care system in which prices are going up—we need to get them to be the captain of their own ship as soon as we can."

    Rhon would like to see the United States enhance its role as one of the world's top providers of quality medical care. To do that, he says, certain changes are needed. "We're never going to be able to do it only by improving treatments for diseases that already are out there," he says. "We've got to incorporate prevention and health promotion to get ahead of the problem. That's critical. Physical therapists have an opportunity to lead the way—set the example and work toward this holistic paradigm."

    Katherine Malmo is a freelance writer.

    References

    1. Nathan ML. The patient-centered medical home in the transformation from healthcare to health. Mil Med. 2013;178(2):126-127. https://academic.oup.com/milmed/article/178/2/126/4210896. Accessed April 25, 2019.
    2. American Holistic Health Association. Principles of Holistic Medicine [webpage]. https://ahha.org/selfhelp-articles/principles-of-holistic-medicine/ Accessed April 25, 2019.
    3. National Center for Complementary and Integrative Health. National Institute of Health. Complementary, Alternative, or Integrative Health: What's In a Name? [webpage] https://nccih.nih.gov/health/integrative-health#hed2. Accessed April 25, 2019.
    4. Wolf WR. Move to Health: Army Medicine Empowers the Patient. May 8, 2015. https://www.army.mil/article/148225/move_to_health_army_medicine_empowers_the_patient. Accessed April 26, 2019.
    5. Ananth S. 2010 complementary and alternative medicine survey of hospitals. Samueli Institute. http://www.samueliinstitute.org/File%20Library/Our%20Research/OHE/CAM_Survey_2010_oct6.pdf. Accessed April 26, 2019.
    6. Misra SM, Guffey D, Tran X, et al. Survey of complementary and alternative medicine (CAM) services in freestanding US children's hospitals. Clin Pediatr. 2017;56(1):33-36.
    7. Pacific College of Oriental Medicine. Holistic Opportunities Abound in US Hospitals: New Integrative Programs Offer Opportunities for Parents & Practitioners Alike [blog post]. https://www.pacificcollege.edu/news/blog/2015/03/22/holistic-opportunities-abound-us-hospitals-new-integrative-programs-offer-opportunities-patients-practitioners-alike. Accessed April 25, 2019.
    8. Busse M, Quinn L, Drew C, et al. Physical activity self-management and coaching compared to social interaction in Huntington's disease: results from the ENGAGE-HD randomized, controlled, pilot feasibility trial. Phys Ther. 2017; 97(6): 625-639.

    The Components of Holistic Health

    The US military's model of holistic health puts the individual at the core, surrounded by elements of self-care—the "holistic wheel"—all of which is encircled by the delivery of health and a healthy environment.

    Each patient, according to this model, must determine his or her motivations and goals. In a preconference course presented by APTA's Federal Physical Therapy Section at the Combined Sections Meeting in 2019, attendees were advised: "Questions to help an individual explore this area include: ‘What really matters to you in your life? What do you want your health for? What is your vision of your best possible health?'"

    Per the course materials, the 9 elements of self-care are:

    Mindfulness. "Mindfulness is being fully aware, or paying attention in the present without judgment of what is there. Being mindful, or aware, allows you to make conscious, proactive choices about every aspect of your health."

    Sleep. "Sleep is very important for your body and mind. Rest can give you peace. Relaxation can lower stress….A good balance between activity and rest improves your health and well-being."

    Activity. "Exercise gives you energy and strength. Movement can make you more flexible. Exercise is also good for your mind….Examples of exercise and movement include walking, gardening, dancing, or lifting weights. Find what works for you."

    Nutrition. "What you eat and drink nourishes your body and mind. Choose healthy eating habits that fit your lifestyle….Keep your body and mind properly fueled."

    Personal development. "Your personal and work lives are very important. How do you spend your time and energy during the day? Do things give you energy or make you tired? Do you spend time doing what matters most to you?"

    Surroundings. "Your environment can affect your health. You may have problems with safety, or things like clutter, noise, bad smells, poor lighting, or water quality. You may be able to change some of these problems. You may not be able to change them all….Improve what you can."

    Emotional. "Your mind can affect your body….Learn to use the connection between your mind and body. Warriors and athletes use the power of the mind to visualize a successful mission or event. Mind-body practices tap into the power of the mind to heal and cope."

    Spiritual. "Where do you turn for strength and comfort? Some people turn to spiritual or religious faith. Some people find comfort in nature. Some connect with art, music, or quiet time alone. Some want to help others."

    Family/social. "Feeling alone can sometimes make you get sick or keep you sick. Positive social relationships are healthy. A healthy intimate relationship with a life partner can be a source of strength. It's good to talk to people who care about you and listen to you."

    Sleep

    Promoting Sleep: Not a Leap

    PT in Motion

    Are You "Woke" oN Sleep

    PT in Motion [online only]

    Sleep Health Promotion: Practical Information for Physical Therapists

    Physical Therapy

    Integrating Sleep Health Into Physical Therapist Clinical Practice

    APTA Learning Center (Course LMS-867)

    Nutrition

    Nutrition and Physical Therapy

    APTA Resource Page

    Nutrition and Physical Therapy: A Powerful Combination

    The Pulse

    Nutrition: A Portion of PTs' Menu of Services

    PT in Motion

    Integrating Functional Nutrition into Practice

    APTA Learning Center (Course LMS-E237)

    Nutritional Screening and Intervention for the Home Health Therapist

    APTA Learning Center (Course LMS-974)

    The Importance of the Gut Microbiome and the Impact That It Can Have on Our Patients

    APTA Learning Center (Course LMS-903)

    Complementary and Integrative Interventions

    APTA Policy

    Integrative Medicine: New Opportunities for PTs

    PT in Motion

    Mindfulness

    Mindfulness: How It Can Help Patients, PTs, and Students

    PT in Motion

    Incorporating Mindfulness into Physical Therapy Practice

    CSM 2018

    Improving Pain Treatment with Mindfulness

    APTA Learning Center (Course LMS-869)

    Rewiring the Brain to Ease Chronic Pain

    PT in Motion

    Other Resources

    Holistic Medicine

    Movement Therapies

    Music, Art, and Dance Therapies


    Comments

    Can anyone please tell me why the APTA does not have a MINDFUL MOVEMENT SPECIAL SECTION?? We have canine, we have oncology, we have orthopedics, as a profession we are missing out on a huge bridge to an industry that is booming and more and more patients are seeking out mindful movement specialists - there are many many PTs who are internationally certified in Pilates or Yoga or Meditation - APTA - come to the table and get this started!
    Posted by samantha s schmidt on 6/30/2019 2:26:23 PM
    Why do we have to keep repeating the same logical steps for optimal treatment of patients? When will this system / approach to Medical Care/ Treatment become the expected and understood approach to optimal treatment ? What will it take to ensure that in America this is the basic expected SYSTEM of MEDICAL CARE/ TREATMENT for ALL PATIENTS regardless of the Treatment / Delivery care center.?
    Posted by Anne Kenny on 7/4/2019 5:36:32 PM
    Physical Therapy has a deeper meaning in our healthcare profession and it includes everything from diagnosing, examining, and offering treatments of issues related to mobility and the performance of specific parts of our body.
    Posted by Modern Med Centers -> DMTZ=K on 10/10/2019 2:28:57 AM

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